Smoking in Italy 2005-2006: effects of a comprehensive National Tobacco Regulation

Association of national smoke-free policies with per-capita cigarette consumption and acute myocardial infarction mortality in Europe

BACKGROUND

Evidence on the association between smoke-free policies and per-capita cigarette consumption and mortality due to acute myocardial infarction (AMI) in Europe is limited. Hence, we aimed to assess this association and to evaluate which factors influence it.

METHODS

We performed an interrupted time series analysis, including 27 member states of the European Union and the UK, on per-capita cigarette consumption and AMI mortality.A multivariate meta-regression was used to assess the potential influence of other factors on the observed associations.

RESULTS

Around half of the smoke-free policies introduced were associated with a level or slope change, or both, of per-capita cigarette consumption and AMI mortality (17 of 35). As for cigarette consumption, the strongest level reduction was observed for the smoking ban issued in 2010 in Poland (rate ratio (RR): 0.47; 95% CI: 0.41, 0.53). Instead, the largest level reduction of AMI mortality was observed for the intervention introduced in 2012 in Bulgaria (RR: 0.38; 95% CI: 0.34, 0.42).Policies issued more recently or by countries with a lower human development index were found to be associated with a larger decrease in per-capita cigarette consumption. In addition, smoking bans applying to bars had a stronger inverse association with both cigarette consumption and AMI mortality.

CONCLUSIONS

The results of our study suggest that smoke-free policies are effective at reducing per-capita cigarette consumption and AMI mortality. It is extremely important to monitor and register data on tobacco, its prevalence and consumption to be able to tackle its health effects with concerted efforts.

Price Policy and Taxation as Effective Strategies for Tobacco Control

Objective

Only 13% of the world's population are living in countries imposing appropriate tobacco tax-rates. This study aims to promote the implementation of price policy measures as a striking tobacco control strategy in Austria and to encourage other countries to further increase their taxes to WHO best-practice levels.

Method

This study used the yearly economic data from Austria from 1997 to 2015. Applying a model for regression analysis, the price elasticity of total tobacco consumption was estimated.

Results

Between 1997 and 2015 the price elasticity of demand for tobacco products (including cigarettes, cigars, and other tobaccos) was -0.661, however, the result is statistically insignificant. When excluding 2 anomalous years and removing a variable of the regression model the elasticity was -0.691 and statistically significant, indicating that a 1% increase in tobacco prices will result in a 0.691% decrease of tobacco consumption.

Conclusion

The responsiveness of Austrian smokers to price changes has increased during the last decades. Because other activities showed no significance in the analysis, this study should encourage countries world-wide to use price policy and taxation more intensively in order to reduce smoking rates effectively.

Secondhand smoke exposure for different education levels: findings from a large, nationally representative survey in Turkey

OBJECTIVES

The aim of this study is to determine the factors that influence individuals' exposure to tobacco smoke in Turkey according to their education level.

DESIGN

Secondary data analysis.

PARTICIPANTS

Altogether, 17 084 individuals aged 15 and over were included in this study.

SETTINGS

Data set of the Turkey Health Survey in 2019.

METHODS

Binary logistic regression analysis was used to determine the factors associated with individuals' exposure to tobacco smoke.

PRIMARY AND SECONDARY OUTCOME MEASURES

The variables age, gender, marital status, general health status, employment status, receipt of psychosocial support and tobacco use were found to be correlated with exposure to tobacco smoke.

RESULTS

The study determined that individuals who are illiterate/unschooled were exposed to tobacco smoke at a rate of 32.61%, primary school graduates at a rate of 34.32%, primary education graduates at a rate of 41.75%, high school graduates at a rate of 41.04% and university graduates at a rate of 40.34%.

CONCLUSION

As a result of the study, it is emphasised that men, young individuals, individuals with moderate and very good general health status, those who use tobacco, those who are unemployed and those who receive psychosocial support should be targeted. In addition, appropriate strategies for reducing secondhand smoke (SHS) exposure should be developed, taking into account public health strategies for increasing awareness of the adverse health effects of SHS exposure and the determinants of tobacco exposure according to the study.

Changes in tobacco use patterns and motivation to quit related to the new smoke-free legislation in the Czech Republic

BACKGROUND

Smoke-free policy belongs to key public health instruments to promote health in populations. In 2017, new comprehensive smoke-free law prohibiting smoking in indoor public places was implemented. We aimed to measure changes in tobacco smoking patterns and changes in motivation to quit in adult smokers prior to and after the new smoke-free legislation came into force.

METHODS

We conducted a prospective cohort study prior to and post the implementation of Act No. 65/2017 Coll. Self-reported questionnaires were administered to 131 adult smokers by trained nurses in general practitioner offices in Prague. We analysed changes in cigarette consumption per day; ratio of cigarettes smoked in pub, street, work and home; and motivation to quit using regression modelling.

RESULTS

We found a statistically significant decrease in the daily consumption of cigarettes (an average of 1.7 cigarettes per day, P < 0.001, d = 0.34). Smoking in indoor public spaces decreased to almost zero, while tobacco consumption in outdoor public spaces (such as streets and squares) increased by nearly 20%. We observed statistically significant increase of motivation to quit smoking (P = 0.021, d = 0.21).

CONCLUSION

The study brings valuable indication of the desired public health impact related to key legislative change in the Czech Republic.

Socio-Economic and Demographic Correlates of Non-communicable Disease Risk Factors Among Adults in Saudi Arabia

Background: Over the past two decades, Saudi Arabia has made significant improvements in its population's health standards. These improvements have been coupled with an increase in risk factors related to non-communicable diseases (NCD) and a dramatic shift in the burden of disease profile. This study aims to provide empirical evidence on the socio-economic and demographic correlates of NCD risk factors among adults in Saudi Arabia.

Methods: The data used for this study is secondary data derived from the Saudi Health Interview Survey (SHIS) conducted in 2013. The SHIS used a cross-sectional survey design to derive a multistage representative sample of adults to estimate the prevalence of NCD risk factors. Risk factors considered for analyses in this study were; current tobacco use, low fruit and vegetable consumption, low physical activity, overweight/obesity and hypertension. The survey covered all regions in Saudi Arabia using probability proportional to size measures. A total of 10,735 adults aged 15 years and above completed the survey questionnaire. Logistic regression analysis was conducted to examine the socio-economic and demographic correlates of NCD risk factors among adults in Saudi Arabia.

Results: The prevalence of NCD risk factors were as follows: current tobacco use, 12.1%; low fruit and vegetable consumption, 87%; low physical activity, 94.9%; overweight/obesity 65.1%; and hypertension, 37.5%. The multivariate analysis results indicate that significant correlates of overweight/obesity and hypertension were being female, a government employee, income level, and education levels. On the other hand, current tobacco use and low fruit and vegetable consumption were generally associated with age, self-employment and being a student. For lifestyle factors, overweight/obesity was high among individuals who reported low fruit and vegetable consumption, while hypertension was high among current tobacco users and overweight/obese adults. All comparisons were statistically significant at p < 0.05.

Conclusions: This study's findings indicate a high prevalence of chronic NCD risk factors in Saudi Arabia's adult population. This study implied that there is a need for a reduction in life-damaging behaviors among the adults through the adoption of healthy lifestyles such as physical activity and nutritious diets. Moreover, a reduction in the prevalence of chronic NCD risk factors among different socio-economic groups in Saudi Arabia through healthy lifestyles will have far-reaching results.

County Smoke-Free Laws and Cigarette Smoking Among U.S. Adults, 1995-2015

INTRODUCTION

Tobacco use remains the leading cause of preventable death worldwide. Though research on smoke-free policies in the U.S. exists at the state or national level, there is limited evidence on such policies at the county level. This study examined the association between changes in county-level comprehensive smoke-free laws and smoking behavior among U.S. adults.

METHODS

Data were used from the 1995/1996 to the 2014/2015 Tobacco Use Supplement to the Current Population Survey, analyzed in 2019. Changes in county smoke-free law population coverage over time were used as a natural experiment. Quasi-experimental analyses were performed to examine the association between changes in county-level comprehensive smoke-free laws and smoking behavior (smoking status and number of cigarettes smoked).

RESULTS

During the study period, current smoking prevalence decreased from 21.6% to 11.9%. Specifically, the prevalence of every day smoking decreased from 17.1% to 9.1% and some days smoking decreased from 4.4% to 2.9%. The number of cigarettes smoked per day for every day smokers decreased from 18.5 to 13.6, and from 5.9 to 4.1 for those who smoked some days. Comprehensive smoke-free legislation was associated with lower odds of cigarette smoking (AOR=0.76, 95% CI=0.74, 0.79). Adults living in counties with comprehensive smoke-free policies smoked fewer cigarettes per day both for every day smokers (β= -1.55, p<0.0001) and some days smokers (β= -0.79, p<0.0001).

CONCLUSIONS

County smoke-free policies in the U.S. may have contributed significantly to the reduction in smoking prevalence as well as the reduction in the number of cigarettes smoked among continuing cigarette smokers.

Passive Smoking Indicators in Italy: Does the Gross Domestic Product Matter?

Background: The aim of this study is to analyse the correlation between regional values of Gross Domestic Product (GDP) and passive smoking in Italy. Methods: The outcome measures were smoking ban respect in public places, workplaces and at home, derived from the PASSI surveillance for the period 2011–2017. The explanatory variable was GDP per capita. The statistical analysis was carried out using bivariate and linear regression analyses, taking into consideration two different periods, Years 2011–2014 and 2014–2017. Results: GDP is showed to be positively correlated with smoking ban respect in public places (r = 0.779 p < 0.001; r = 0.723 p < 0.001 in the two periods, respectively), as well as smoking ban respect in the workplace (r = 0.662 p = 0.001; r = 0.603 p = 0.004) and no smoking at home adherence (r = 0.424 p = 0.056; r = 0.362 p = 0.107). In multiple linear regression GDP is significantly associated to smoking ban respect in public places (adjusted β = 0.730 p < 0.001; β = 0.698 p < 0.001 in the two periods, respectively), smoking ban in workplaces (adjusted β = 0.525 p = 0.020; β = 0.570 p = 0.009) and no smoking at home (adjusted β = 0.332 p = 0.070; β = 0.362 p = 0.052). Conclusions: Smoking ban is more respected in Regions with higher GDP. For a better health promotion, systematic vigilance and sanctions should be maintained and strengthened, particularly in regions with low compliance with smoking bans.

Associations of Bar and Restaurant Smoking Bans With Smoking Behavior in the CARDIA Study: A 25-Year Study

Indoor smoking bans have often been associated with reductions in smoking prevalence. However, few studies have evaluated their association with within-person changes in smoking behaviors. We linked longitudinal data from 5,105 adults aged 18-30 years at baseline from the Coronary Artery Risk Development in Young Adults (CARDIA) Study (1985-2011) to state, county, and local policies mandating 100% smoke-free bars and restaurants by census tract. We used fixed-effects models to examine the association of smoking bans with within-person change in current smoking risk, smoking intensity (smoking ≥10 cigarettes/day on average vs. <10 cigarettes/day), and quitting attempts, using both linear and nonlinear adjustment for secular trends. In models assuming a linear secular trend, smoking bans were associated with a decline in current smoking risk and smoking intensity and an increased likelihood of a quitting attempt. The association with current smoking was greatest among participants with a bachelor's degree or higher. In models with a nonlinear secular trend, pooled results were attenuated (confidence intervals included the null), but effect modification results were largely unchanged. Findings suggest that smoking ban associations may be difficult to disentangle from other tobacco control interventions and emphasize the importance of evaluating equity throughout policy implementation.

Smoking in young and adult population, Italy 2009

Aims and background

To monitor smoking prevalence and trends of young and adult populations in Italy.

Method and study design

A survey on smoking was conducted during March-April 2009 on a sample of 3213 participants (1546 men and 1667 women), representative of the Italian population aged 15 years or over. Data from a simplified questionnaire were collected in an over-sample of 1010 young individuals, reaching a total of 1390 participants aged 15–24 years (713 males and 677 females).

Results

In 2009, 25.4% of Italians described themselves as current cigarette smokers (28.9% of men and 22.3% of women). Among young people, male smoking prevalence steadily declined from 38% in 2001 to 29% in 2009. Smoking prevalence in young females decreased from 30% in 2001 to 19% in 2008, but increased to 23% in 2009. Among both males and females aged 15–17 years, smoking prevalence was around 10%. This increased in the 18–24 year age group, with 37.6% of current smokers among males and 28.9% among females. Among young current smokers, 45.5% reported that they would reduce the number of cigarettes smoked per day, 11.1% would quit smoking, and 4.3% would switch to hand-rolled cigarettes, assuming that the minimum price of a pack of cigarettes increased to €5.

Conclusions

Our findings indicate that smoking prevalence has decreased over recent years, particularly in the young. Still, over one-fourth of Italian adults are smokers. An increase in cigarette price represents an effective strategy to control tobacco, particularly in the young.

Gastric Cancer Mortality Trends in Tuscany, Italy, 1971–2004

Aims, Background, and Methods

In Tuscany, Italy, gastric cancer mortality has been decreasing since 1950, although with relevant geographical variability across the region. In Eastern Tuscan areas close to the mountains (high risk areas), gastric cancer mortality has been and is still significantly higher than that recorded in Western coastal areas and in the city of Florence (low risk areas). High-risk areas also showed higher Helicobacter pylori seroprevalence. Aim of this paper is to study gastric cancer mortality trends in high and low-risk areas, during the period 1971–2004, using age-period-cohort models.

Results

In high-risk areas, gastric cancer mortality rates declined from 61.4 per 100,000 in 1971–74 to 19.8 in 2000–2004 and in low-risk areas from 34.9 to 9.8. Mortality decline in high-risk areas was mainly attributable to a birth cohort effect, whereas in low-risk areas it was due either to a birth cohort effect or a period effect. In low- and high-risk areas, birth-cohort risks of dying decreased over subsequent generations, except for the birth cohorts born around the second world war.

Conclusions

Gastric cancer mortality in areas with higher H. pylori seroprevalence in Tuscany (high-risk areas) showed a predominant decline by birth cohort, in particular for younger generations, possibly due to the decrease of the infection for improvement of living conditions.

Smoking in Italy 2007, with a Focus on the Young

Aims and Background

Although smoking has been on the decline in Italy, its prevalence is still high among younger individuals. We analyzed data from the 2007 tobacco survey and present the findings on smoking prevalence by selected characteristics, with a particular focus on the young.

Methods

The data were collected from 3,057 Italians aged 15 years and older in March and April 2007 who were randomly selected to be representative of the general Italian population. The prevalence of self-reported current smoking was estimated overall and by age group, education, geographic region, and gender. Additionally, intentions to quit and trends in smoking in the total population and among individuals aged 15–24 years were estimated.

Results

The smoking prevalence overall was 23.5% (27.9% among males and 19.3% among females), with higher estimates among adults living in central regions and among men with a lower educational level. Among individuals aged 15–24 years, since 2001 the male prevalence has fluctuated between 30% and 35% and the female prevalence between 20% and 25%. Overall, the prevalence decreased by approximately 40% in this age group. A small percentage (3.3%) reported having intention to quit smoking in the next 6 months.

Conclusions

The smoking prevalence is the lowest estimate reported since 1957, and the gap between men and women has diminished. Compared to earlier birth cohorts, the lower current estimate among younger adults suggests that the rates will decrease in the future.

Prevalence of Second-Hand Smoke Exposure After Introduction of the Italian Smoking Ban: The Florence and Belluno Survey

Aims and Background

A law banning smoking in enclosed public places was implemented in Italy on January 10, 2005. The aim of this paper is to present a cross-sectional survey on two representative samples of non-smokers of two Italian towns (Florence and Belluno), conducted one year after the introduction of the ban, in order to assess prevalence of second-hand smoke exposure, to record the attitudes towards the ban, and the perception about its compliance in a representative sample of non-smokers.

Methods

Computer-assisted telephone interviews were carried out in March 2006, from a random sample of households from telephone registries. Respondents were 402 non-smokers from Belluno and 1,073 from Florence.

Results

About 12% of Florentines and 7% of Belluno respondents were exposed at home; 39% and 19%, respectively, at work; 10% and 5% in hospitality venues; 20% and 10% in cars. The smoke-free law was almost universally supported (about 98%) even if a smaller proportion of people (about 90%) had the perception that the ban was observed.

Conclusions

Second-hand smoke exposure at home and in hospitality premises has dropped to ≤10%, whereas exposure at work remained higher. These results suggest the need for more controls in workplaces other than hospitality venues.

Legislative smoking bans for reducing harms from secondhand smoke exposure, smoking prevalence and tobacco consumption

BACKGROUND

Smoking bans have been implemented in a variety of settings, as well as being part of policy in many jurisdictions to protect the public and employees from the harmful effects of secondhand smoke (SHS). They also offer the potential to influence social norms and the smoking behaviour of those populations they affect. Since the first version of this review in 2010, more countries have introduced national smoking legislation banning indoor smoking.

OBJECTIVES

To assess the effects of legislative smoking bans on (1) morbidity and mortality from exposure to secondhand smoke, and (2) smoking prevalence and tobacco consumption.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, MEDLINE, EMBASE, PsycINFO, CINAHL and reference lists of included studies. We also checked websites of various organisations. Date of most recent search; February 2015.

SELECTION CRITERIA

We considered studies that reported legislative smoking bans affecting populations. The minimum standard was having an indoor smoking ban explicitly in the study and a minimum of six months follow-up for measures of smoking behaviour. Our search included a broad range of research designs including: randomized controlled trials, quasi-experimental studies (i.e. non-randomized controlled studies), controlled before-and-after studies, interrupted time series as defined by the Cochrane Effective Practice and Organisation of Care Group, and uncontrolled pre- and post-ban data.

DATA COLLECTION AND ANALYSIS

One author extracted characteristics and content of the interventions, participants, outcomes and methods of the included studies and a second author checked the details. We extracted health and smoking behaviour outcomes. We did not attempt a meta-analysis due to the heterogeneity in design and content of the studies included. We evaluated the studies using qualitative narrative synthesis.

MAIN RESULTS

There are 77 studies included in this updated review. We retained 12 studies from the original review and identified 65 new studies. Evidence from 21 countries is provided in this update, an increase of eight countries from the original review. The nature of the intervention precludes randomized controlled trials. Thirty-six studies used an interrupted time series study design, 23 studies use a controlled before-and-after design and 18 studies are before-and-after studies with no control group; six of these studies use a cohort design. Seventy-two studies reported health outcomes, including cardiovascular (44), respiratory (21), and perinatal outcomes (7). Eleven studies reported national mortality rates for smoking-related diseases. A number of the studies report multiple health outcomes. There is consistent evidence of a positive impact of national smoking bans on improving cardiovascular health outcomes, and reducing mortality for associated smoking-related illnesses. Effects on respiratory and perinatal health were less consistent. We found 24 studies evaluating the impact of national smoke-free legislation on smoking behaviour. Evidence of an impact of legislative bans on smoking prevalence and tobacco consumption is inconsistent, with some studies not detecting additional long-term change in existing trends in prevalence.

AUTHORS' CONCLUSIONS

Since the first version of this review was published, the current evidence provides more robust support for the previous conclusions that the introduction of a legislative smoking ban does lead to improved health outcomes through reduction in SHS for countries and their populations. The clearest evidence is observed in reduced admissions for acute coronary syndrome. There is evidence of reduced mortality from smoking-related illnesses at a national level. There is inconsistent evidence of an impact on respiratory and perinatal health outcomes, and on smoking prevalence and tobacco consumption.

A combined analysis of worldwide studies demonstrates an association between bipolar disorder and tobacco smoking behaviors in adults

OBJECTIVES

Worldwide studies were combined to examine two hypotheses: (i) bipolar disorder is associated with smoking behaviors, compared with the general population; and (ii) smoking behavior prevalences in bipolar disorder are intermediate between those in major depressive disorder and those in schizophrenia.

METHODS

Combined analyses used 56 articles on adults obtained from a PubMed search or the senior author's article collection. Odds ratios (ORs) and their 95% confidence intervals (CIs) compared current smoking, heavy smoking among current smokers, smoking cessation in ever smokers, and ever smoking in bipolar disorder versus control groups.

RESULTS

The combined OR was 3.5 (CI: 3.39-3.54) in 51 current smoking studies of bipolar disorder versus the general population from 16 countries. More limited data provided an OR = 0.34 (CI: 0.31-0.37) for smoking cessation and an OR = 3.6 (CI: 3.30-3.80) for ever smoking. The combined OR was 0.76 (CI: 0.74-0.79) for current smoking in bipolar disorder versus schizophrenia in 20 studies from ten countries. Ever smoking may be lower in bipolar disorder than in schizophrenia (OR = 0.83, CI: 0.75-0.91). The OR was 2.05 (CI: 2.00-2.10) for current smoking in bipolar disorder versus major depression in 18 studies from seven countries. Ever smoking may be higher (OR = 1.5, CI: 1.40-1.70) and smoking cessation lower (OR = 0.51, CI: 0.45-0.59) in bipolar disorder than in major depression.

CONCLUSIONS

Increased current smoking in bipolar disorder versus the general population reflected increased ever smoking (initiation) and decreased smoking cessation. Smoking behavior frequencies in bipolar disorder may be between those in depressive disorder and schizophrenia, with schizophrenia showing the highest severity level.

Changes in the Prevalence of Tobacco Consumption and the Profile of Spanish Smokers after a Comprehensive Smoke-Free Policy

BACKGROUND

A partial smoke-free regulation in Spain was introduced on January 1, 2006, which was subsequently amended to introduce a comprehensive smoke-free policy from 2 January 2011 onward. The objective of this study was to compare the prevalence of tobacco consumption in Spain and the profile of smokers before (2006) and after (2011) the comprehensive smoking ban passed in 2010.

METHODS

Two independent, cross-sectional, population-based surveys were carried out among the adult (≥ 18 years old) Spanish population in 2006 and 2011 through telephone interviews. Both surveys used the same methods and questionnaire. Nicotine dependence was assessed with the Fagerström Test for nicotine dependence and readiness to quit according to the stages of change.

RESULTS

The prevalence of tobacco consumption showed a nonsignificant decrease from 23.4% in 2006 to 20.7% in 2011. No changes were observed in nicotine dependence or readiness to quit. In 2011, most smokers (76%) showed low nicotine dependence and were mainly in the precontemplation stage (72%).

CONCLUSIONS

The prevalence of smokers has slightly decreased since the introduction of the total smoking ban in Spain. No differences were found in nicotine dependence or readiness to quit.

Support for a tobacco endgame strategy in 18 European countries

OBJECTIVE

The feasibility of a tobacco endgame strategy, aiming to bring smoking prevalence to near-zero levels, is currently under debate. We provide information on public support for such a strategy in Europe.

METHODS

In 2010 we conducted a face-to-face representative survey in 18 European countries (Albania, Austria, Bulgaria, the Czech Republic, Croatia, England, Finland, France, Greece, Hungary, Ireland, Italy, Latvia, Poland, Portugal, Romania, Spain and Sweden). The present analysis is based on 16,947 individuals aged ≥ 15 years providing information on their attitudes towards a complete ban on the use or sale of tobacco.

RESULTS

Overall, 34.9% of adults (32.8% in men and 37.0% in women; p<0.001) supported a complete ban strategy on use or sale of tobacco, 41.2% of never, 29.4% of ex- and 25.6% of current smokers. The highest support was observed in southern Europe (42.5%), followed by eastern (39.1%), northern (27.5%) and western Europe (23.0%; p<0.001). A significant inverse trend was observed with both age and education.

CONCLUSION

Approximately one in three adults (and one in four smokers) supports a comprehensive tobacco endgame intervention. This first study in Europe provides a baseline for evaluating future trends in public support for extreme propositions to end or drastically cut smoking.

Cardiovascular Events Following Smoke-Free Legislations: An Updated Systematic Review and Meta-Analysis

BACKGROUND

Legislations banning smoking in indoor public places and workplaces are being implemented worldwide to protect the population from secondhand smoke exposure. Several studies have reported reductions in hospitalizations for acute coronary events following the enactment of smoke-free laws.

OBJECTIVE

We set out to conduct a systematic review and meta-analysis of epidemiologic studies examining how legislations that ban smoking in indoor public places impact the risk of acute coronary events.

METHODS

We searched MEDLINE, EMBASE, and relevant bibliographies including previous systematic reviews for studies that evaluated changes in acute coronary events, following implementation of smoke-free legislations. Studies were identified through December 2013. We pooled relative risk (RR) estimates for acute coronary events comparing post- vs. pre-legislation using inverse-variance weighted random-effects models.

RESULTS

Thirty-one studies providing estimates for 47 locations were included. The legislations were implemented between 1991 and 2010. Following the enactment of smoke-free legislations, there was a 12 % reduction in hospitalizations for acute coronary events (pooled RR: 0.88, 95 % CI: 0.85-0.90). Reductions were 14 % in locations that implemented comprehensive legislations compared to an 8 % reduction in locations that only had partial restrictions. In locations with reductions in smoking prevalence post-legislation above the mean (2.1 % reduction) there was a 14 % reduction in events compared to 10 % in locations below the mean. The RRs for acute coronary events associated with enacting smoke-free legislation were 0.87 vs. 0.89 in locations with smoking prevalence pre-legislation above and below the mean (23.1 %), and 0.87 vs. 0.89 in studies from the Americas vs. other regions.

CONCLUSION

The implementation of smoke-free legislations was related to reductions in acute coronary event hospitalizations in most populations evaluated. Benefits are greater in locations with comprehensive legislations and with greater reduction in smoking prevalence post-legislation. These cardiovascular benefits reinforce the urgent need to enact and enforce smoke-free legislations that protect all citizens around the world from exposure to tobacco smoke in public places.

Smoking ban policies in Italy and the potential impact of the so-called Sirchia Law: state of the art after eight years

OBJECTIVE

The aim of the present work is to describe the state of the art of tobacco habits in Italy, eight years after the law was introduced.

METHODS

Time series analyses, based on estimates of smoking prevalence/consumption derived from the openly available data of national surveys performed during the 2001-2013 period, were performed. Data have been expressed in percentage of smokers and daily cigarettes consumption. Time changes are expressed as expected annual percentage change (EAPC).

RESULTS

Over time, the percentage of Italian smokers shows a constant and statistically significant decrease (from 28.9% in 2001 to 20.6% in 2013, EAPC = -2.6%, and P < 0.001). Regarding data stratified by gender, we found a stronger reduction among men (EAPC = -2.9%, P < 0.001) than in women (EAPC = -2.5%, P < 0.001). Similarly, the consumption of tobacco smoking, measured as the number of daily cigarettes smoked, registered a downward trend (P < 0.001). No join point (time point when a significant trend change is detected) resulted from the trend analysis.

CONCLUSIONS

Data show a constant decrease of tobacco consumption in Italy, with no join point related to the introduction of the banning law. These findings require to reflect on the priorities of the smoking banning policies that may be focused on other intervention activities such as to increase the price of cigarettes.

The effect of Philadelphia and Pennsylvania Clean Indoor Air Act on food services and drinking places sales and numbers, 1998-2011

Introduction

Philadelphia enacted its Clean Indoor Air Act (CIAA) nearly 2 years before the statewide CIAA. In this study, we assessed the economic impact of CIAAs on 4 types of food services and drinking places and addressed the predominant limitation of previous pre–post ban studies, namely the lack of control for confounders and changes in secular trends over time.

Methods

We analyzed data from Pennsylvania Department of Revenue Quarterly 1998–2011 taxable county-level revenue sales and number of food services and drinking places. Region-specific and type-specific adjusted sales and number of food services and drinking places accounted for consumer spending as a general economic indicator. Segmented regression analysis of interrupted time-series methodology assessed changes in trend and level.

Results

Pennsylvania CIAA had no significant effect on adjusted sales or numbers except for an increase in sales in Philadelphia for limited-service eating places and in the surrounding 4 counties for special food services. Philadelphia CIAA was associated with an increase in adjusted numbers of full-service restaurants in Philadelphia and the rest of the state, special food services in Philadelphia, and drinking places in the rest of the state, and a decrease in the number of special food services in the surrounding counties. Philadelphia CIAA had no significant effect on adjusted sales except for an increase in special food services in the rest of the state.

Conclusion

Overall, CIAAs had no negative business-related impact and, for the most part, suggest a positive impact on restaurant sales and numbers. Our results provide further support for comprehensive CIAA ordinance for restaurants.

The effects of smoke-free legislation on acute myocardial infarction: a systematic review and meta-analysis

Background

Comprehensive smoke-free legislation has been implemented in many countries. The current study quantitatively examined the reduction in risk of acute myocardial infarction (MI) occurrence following the legislations and the relationship with the corresponding smoking prevalence decrease.

Methods

PubMed, EMBASE, and Google Scholar databases and bibliographies of relevant studies and reviews were searched for potential original studies published from January 1, 2004, through October 31, 2011. Meta-analysis was performed using a random effect model to estimate the overall effects of the smoking-free legislations. Meta-regression was used to investigate possible causes of heterogeneity in risk estimates.

Results

A total of 18 eligible studies with 44 estimates of effect size were used in this study. Meta-analysis produced a pooled estimate of the relative risk of 0.87 (95% confidence interval (CI): 0.84 to 0.91). There was significant heterogeneity in the risk estimates (overall I² = 96.03%, p<0.001). In meta-regression analysis, studies with greater smoking prevalence decrease produced larger relative risk (adjusted coefficient −0.027, 95% CI: -0.049 to −0.006, p=0.014).

Conclusion

Smoke-free legislations in public and work places were associated with significant reduction in acute MI risk, which might be partly attributable to reduced smoking prevalence.

The role of anti-smoking legislation on cigarette and alcohol consumption habits in Italy

The short-term effects of public smoking bans on individual smoking and drinking habits were investigated in this paper. In 2005, a smoking ban was introduced in Italy, and we exploited this exogenous variation to measure the effect on both smoking participation and intensity and the indirect effect on alcohol consumption. Using data from the Everyday Life Aspects survey, for the period 2001-2007, we show that the introduction of smoke-free legislation in Italy significantly affected smoking behavior. We also document significant indirect effects on alcohol consumption for the main alcoholic beverage categories. A robustness analysis is also performed, to test the extent to which unobservable variables may bias our estimated parameters. Our results are then used to perform a cost-effectiveness analysis of the anti-smoking legislation in Italy.

Are women who smoke at higher risk for lung cancer than men who smoke?

Worldwide lung cancer incidence is decreasing or leveling off among men, but rising among women. Sex differences in associations of tobacco carcinogens with lung cancer risk have been hypothesized, but the epidemiologic evidence is conflicting. We tested sex-smoking interaction in association with lung cancer risk within a population-based case-control study, the Environment and Genetics in Lung Cancer Etiology (EAGLE) Study (Lombardy, Italy, 2002-2005). Detailed lifetime smoking histories were collected by personal interview in 2,100 cases with incident lung cancer and 2,120 controls. Odds ratios and 95% confidence intervals for pack-years of cigarette smoking were estimated by logistic regression, adjusted for age, residence area, and time since quitting smoking. To assess sex-smoking interaction, we compared the slopes of odds ratios for logarithm of pack-years in a model for men and women combined. Overall, the slope for pack-years was steeper in men (odds ratio for female-smoking interaction = 0.39, 95% confidence interval: 0.24, 0.62; P < 0.0001); after restriction to ever smokers, the difference in slopes was much smaller (odds ratio for interaction = 0.63, 95% confidence interval: 0.29, 1.37; P = 0.24). Similar results were found by histological type. Results were unchanged when additional confounders were evaluated (e.g., tobacco type, inhalation depth, Fagerström-assessed nicotine dependence). These findings do not support a higher female susceptibility to tobacco-related lung cancer.

Impact of a stepwise introduction of smoke-free legislation on the rate of preterm births: analysis of routinely collected birth data

OBJECTIVE

To investigate the incidence of preterm delivery in the Belgian population after implementation of smoke-free legislation in three phases (in public places and most workplaces January 2006, in restaurants January 2007, and in bars serving food January 2010).

DESIGN

Logistic regression analyses on routinely collected birth data from January 2002 to December 2011.

SETTING

Flanders, Belgium.

POPULATION

All live born singleton births delivered at 24-44 weeks of gestation (n = 606,877, with n = 448,520 spontaneous deliveries).

MAIN OUTCOME MEASURES

Preterm birth (gestational age <37 weeks).

RESULTS

We found reductions in the risk of preterm birth after the introduction of each phase of the smoking ban. No decreasing trend was evident in the years or months before the bans. We observed a step change in the risk of spontaneous preterm delivery of -3.13% (95% CI -4.37% to -1.87%; P<0.01) on 1 January 2007 (ban on smoking in restaurants), and an annual slope change of -2.65% (-5.11% to -0.13%; P=0.04) after 1 January 2010 (ban on smoking in bars serving food). The analysis for all births gave similar results: a step change of -3.18% (-5.38% to -0.94%; P<0.01) on 1 January 2007, and an annual slope change of -3.50% (-6.35% to -0.57%; P=0.02) after 1 January 2010. These changes could not be explained by personal factors (infant sex, maternal age, parity, socioeconomic status, national origin, level of urbanisation); time related factors (underlying trends, month of the year, day of the week); or population related factors (public holidays, influenza epidemics, and short term changes in apparent temperature and particulate air pollution).

CONCLUSION

Our study shows a consistent pattern of reduction in the risk of preterm delivery with successive population interventions to restrict smoking. This finding is not definitive but it supports the notion that smoking bans have public health benefits from early life.

Cigarette smoking and endometrial cancer risk: the modifying effect of obesity

The objective of this study was to evaluate the association between cigarette smoking and endometrial cancer risk by investigating potential modifying effects of menopausal status, obesity, and exogenous hormones. We pooled data from three case-control studies with the same study design conducted in Italy and Switzerland between 1982 and 2006. Overall, 1446 incident endometrial cancers and 4076 hospital controls were enrolled. Odds ratios (OR) and 95% confidence intervals (CI) were estimated using logistic regression models, conditioned on study and centre, and adjusted for age, period of interview, age at menarche, parity, and body mass index. In comparison with never smokers, current smokers showed reduced endometrial cancer risk (OR: 0.80; 95% CI: 0.66-0.96), with a 28% decrease in risk for smoking ≥ 20 cigarettes/day. The association did not vary according to menopausal status, oral contraceptive use, or hormone replacement therapy. However, heterogeneity emerged according to body mass index among postmenopausal women, with obese women showing the greatest risk reduction for current smoking (OR: 0.47; 95% CI: 0.27-0.81). In postmenopausal women, obesity turned out to be an important modifier of the association between cigarette smoking and the risk of endometrial cancer. This finding calls for caution in interpreting the favorable effects of cigarette smoking, considering the toxic and carcinogenic effects of tobacco.

The Effect of Comprehensive Smoking Bans in European Workplaces

Many European countries have recently implemented comprehensive smoking bans to reduce exposure to tobacco smoke in public places and all indoor workplaces. We use a difference-in-differences approach and comparable microdata for a number of European countries to evaluate the impact of national comprehensive smoking bans on workers’ perceived health. Results show that the introduction of comprehensive smoking bans has a significant effect on the probability of both exposure to smoke and work-related respiratory problems. We also highlight unintended effects in terms of mental distress. The impact across countries is shown to vary with the degree of strictness of the bans.

Impact of the 2005 smoke-free policy in Italy on prevalence, cessation and intensity of smoking in the overall population and by educational group

AIMS

To estimate the immediate as well as the longer-term impact of the 2005 smoke-free law on smoking prevalence, cessation and intensity both in the overall population and separately by educational level.

DESIGN

Interrupted time-series analyses of 11 cross-sectional nationally representative surveys.

SETTING

Italy, 1999-2010.

PARTICIPANTS

Adults aged 20-64 years.

MEASUREMENTS

For each year we computed the prevalence of current smoking, the quit ratio and the mean number of cigarettes smoked per day. All measures were standardized by age. Segmented linear regression analyses were performed for each smoking variable separately by sex.

FINDINGS

Among males, smoking prevalence decreased by 2.6% (P = 0.002) and smoking cessation increased by 3.3% (P = 0.006) shortly after the ban, but both measures tended to return to pre-ban values in the following years. This occurred among both highly and low-educated males. Among low-educated females, the ban was followed by a 1.6% decrease (P = 0.120) in smoking prevalence and a 4.5% increase in quit ratios (P < 0.001). However, these favourable trends reversed over the following years. Among highly educated females, trends in smoking prevalence and cessation were not altered by the ban. Among both males and females, long-term trends in the daily number of cigarettes, which were already declining well before the implementation of the policy, changed to a minor extent.

CONCLUSION

The impact of the Italian smoke-free policy on smoking and inequalities in smoking was short-term. Smoke-free policies may not achieve the secondary effect of reducing smoking prevalence in the long term, and they may have limited effects on inequalities in smoking.

Italy SimSmoke: the effect of tobacco control policies on smoking prevalence and smoking attributable deaths in Italy

Background

While Italy has implemented some tobacco control policies over the last few decades, which resulted in a decreased smoking prevalence, there is still considerable scope to strengthen tobacco control policies consistent with the World Health Organization (WHO) policy guidelines. The present study aims to evaluate the effect of past and project the effect of future tobacco control policies on smoking prevalence and associated premature mortality in Italy.

Methods

To assess, individually and in combination, the effect of seven types of policies, we used the SimSmoke simulation model of tobacco control policy. The model uses population, smoking rates and tobacco control policy data for Italy.

Results

Significant reductions of smoking prevalence and premature mortality can be achieved through tobacco price increases, high intensity media campaigns, comprehensive cessation treatment program, strong health warnings, stricter smoke-free air regulations and advertising bans, and youth access laws. With a comprehensive approach, the smoking prevalence can be decreased by as much as 12% soon after the policies are in place, increasing to a 30% reduction in the next twenty years and a 34% reduction by 30 years in 2040. Without effective tobacco control policies, a total of almost 300 thousand lives will be prematurely lost due to smoking by the year 2040.

Conclusion

Besides presenting the benefits of a comprehensive tobacco control strategy, the model helps identify information gaps in surveillance and evaluation schemes that will promote the effectiveness of future tobacco control policy in Italy.

Public support for smoke-free areas in Israel: a case for action

OBJECTIVE

Secondhand smoke exposure (SHSe) harms adults and children. Though most governments are obliged by international health treaty to protect nonsmokers from SHSe, few adequately do so. Public opinion can provide a powerful mandate for smoke-free policies, but a representative public voice is often absent from the political discussion. For example, following Cabinet approval of a national tobacco control plan, Israel remains embroiled in stormy debate about smoke-free legislation. This debate has unfolded without benefit of current empirical evidence on nationwide public support. The present study reports and assesses public opinion regarding smoke-free places.

METHODS

A nationally representative survey (n=505) was conducted in December, 2010. The response rate was 61%.

RESULTS

Public opinion supports smoke-free air in many places. There was broad consensus among current, former, and never-smokers for smoke-free cars carrying children (94.4%), and smoke-free healthcare facility entrances (92.6%). A clear majority (67.0%) supported completely smoke-free bars and pubs. Nearly half (47.3%) supported eliminating school staff smoking rooms.

CONCLUSIONS

These data strengthen the case for the recent government-approved tobacco control plan. Valid data regarding public opinion on tobacco control can facilitate passage and implementation of smoke-free legislation, thus speeding transition to smoke-free societies.

Second-hand smoke exposure and mitigation strategies among home visitation workers

OBJECTIVES

Protection of workers from second-hand smoke (SHS) in occupational settings is an important policy priority, yet little attention has been given to SHS protection for home visitation health workers, who number almost 2 million in the USA. Self-reported SHS exposure, SHS mitigation strategies and suggestions for further SHS exposure reduction approaches were obtained from home visitation health workers in Massachusetts.

METHODS

A cross-sectional survey was conducted among Massachusetts Early Intervention workers (N=316) at their state-wide conference in April 2010.

RESULTS

Eighty-three per cent of respondents reported at least 1 hour per month of SHS exposure, and 16% reported at least 11 hours per month. Nevertheless, only 22% of workers counselled clients on maintaining a smoke-free home. Fewer than 30% of workers had ever voiced concerns to their employing agency, and just 12% had raised their concerns directly with clients. Only 14% stated that their agency had rules designed to protect workers from SHS.

CONCLUSIONS

SHS exposure occurs frequently among home visitation health workers. The data point to a substantial population who are not protected from SHS exposure by formal policies.

Impact of Scottish smoke-free legislation on smoking quit attempts and prevalence

Objectives

In Scotland, legislation was implemented in March 2006 prohibiting smoking in all wholly or partially enclosed public spaces. We investigated the impact on attempts to quit smoking and smoking prevalence.

Methods

We performed time series models using Box-Jenkins autoregressive integrated moving averages (ARIMA) on monthly data on the gross ingredient cost of all nicotine replacement therapy (NRT) prescribed in Scotland in 2003–2009, and quarterly data on self-reported smoking prevalence between January 1999 and September 2010 from the Scottish Household Survey.

Results

NRT prescription costs were significantly higher than expected over the three months prior to implementation of the legislation. Prescription costs peaked at £1.3 million in March 2006; £292,005.9 (95% CI £260,402.3, £323,609, p<0.001) higher than the monthly norm. Following implementation of the legislation, costs fell exponentially by around 26% per month (95% CI 17%, 35%, p<0.001). Twelve months following implementation, the costs were not significantly different to monthly norms. Smoking prevalence fell by 8.0% overall, from 31.3% in January 1999 to 23.7% in July–September 2010. In the quarter prior to implementation of the legislation, smoking prevalence fell by 1.7% (95% CI 2.4%, 1.0%, p<0.001) more than expected from the underlying trend.

Conclusions

Quit attempts increased in the three months leading up to Scotland's smoke-free legislation, resulting in a fall in smoking prevalence. However, neither has been sustained suggesting the need for additional tobacco control measures and ongoing support.

Effect of smoke-free legislation on adult smoking behaviour in England in the 18 months following implementation

Background

Comprehensive smoke-free legislation covering all enclosed public places and workplaces was implemented in England on 1 July 2007. This study examines the impact of this legislation on smoking prevalence, number of cigarettes smoked and location of smoking, controlling for secular trends through the end of 2008.

Method and Findings

Repeat cross sectional survey using nationally representative data from the Health Survey for England (HSE). In total there are 54,333 respondents from 2003–2008. Logit and linear regression models were used to examine the effect of the legislation on smoking prevalence and the number of cigarettes smoked daily among continuing smokers which took the underlying trend into account. Our finding suggest that smoking prevalence (current smoker) decreased from 25% in 2003 to 21% in 2008 (AOR = 0.96 per year, 95% CI = 0.95–0.98, P<0.01) and the mean number of cigarettes consumed daily by smokers decreased from 14.1 in 2003 to 13.1 in 2008 (coefficient for time trend = −0.28±0.06 SE cig/day per year, P<0.01). After adjusting for these trends the introduction of smoke-free legislation was not associated with additional reductions in smoking prevalence (AOR = 1.02, 95% CI = 0.94–1.11, P = 0.596) or daily cigarette use in smokers (0.42±0.28 SE; P = 0.142). The percentage of respondents reporting smoking ‘at work’ and ‘inside pubs or bars’ decreased significantly from 14% to 2% (p<0.001) and from 34% to 2% (p<0.001), respectively, after the legislation. The percentage reporting smoking ‘inside restaurants, cafes, or canteens’ decreased significantly from 9% to 1% (p<0.001) and ‘inside their home’ decreased significantly from 65% to 55% (p<0.01).

Conclusion

There is widespread compliance with the smoke-free legislation in England, which has led to large drops in indoor smoking in all venues, including at home. Declines in smoking prevalence and consumption continued along existing trends; they did not accelerate during the 18 months immediately following implementation.

Smoking prevalence and smoking attributable mortality in Italy, 2010

OBJECTIVE

To provide updated information on smoking prevalence and attributable mortality in Italy.

METHOD

A representative survey on smoking was conducted in 2010 on a sample of 3020 Italian adults (1453 men and 1567 women). We used SAMMEC software to update smoking attributable mortality in Italy.

RESULTS

In 2010, 21.7% of Italians (23.9% of men and 19.7% of women) described themselves as current smokers. Smoking prevalence was higher in men than in women in all age groups, except for the middle-aged population (45-64 years; 25.6% in men and 25.9% in women). Age-standardized smoking prevalence was higher in men than in women among less educated subjects and in southern Italy. No substantial difference was observed either in educated subjects or in northern and central Italy. Overall, 71,445 deaths in Italy (52,707 men and 18,738 women, 12.5% of total mortality) are attributable to smoking.

CONCLUSION

The overall smoking prevalence of 21.7% in 2010 is the lowest registered over the last 50 years. Since 1998, smoking related deaths declined by almost 15%. Given that Italy has now reached the final stage of the tobacco epidemic, anti-smoking strategies should focus on support for smoking cessation.

The population impact of smoke-free workplace and hospitality industry legislation on smoking behaviour. Findings from a national population survey

AIMS

To study the impact of implementing smoke-free workplace and hospitality industry legislation on smoking behaviour.

DESIGN, SETTING AND PARTICIPANTS

A cross-sectional population survey from 2001 to 2008 (n ≈ 18,000 per year) was used to assess trends and seasonal patterns in smoking and quitting, and to examine whether changes could be observed after the workplace smoking ban in the Netherlands in 2004 and the hospitality industry ban in 2008.

MEASUREMENTS

Outcome measures were smoking prevalence, quit attempts and successful quit attempts. Interactions with educational level (socio-economic status) and bar visiting (exposure to the hospitality industry ban) were tested.

FINDINGS

The workplace ban was followed by a decrease in smoking prevalence (OR = 0.91, P < 0.001), but the hospitality industry ban was not (OR = 0.96, P = 0.127). Both bans, especially the workplace ban, were followed by an increase in quit attempts and successful quit attempts: workplace ban, OR = 1.31, P < 0.001; OR = 1.49, P < 0.001; hospitality industry ban, OR = 1.13, P = 0.013; OR = 1.44, P < 0.001. The workplace ban had a larger effect on successful quitting among higher-educated (OR = 0.35, P < 0.001) than on lower-educated respondents (OR = 0.74, P = 0.052). The hospitality industry ban had a larger effect on quit attempts among frequent bar visitors (OR = 1.48, P = 0.003) than on non-bar visitors (OR = 0.71, P = 0.014).

CONCLUSIONS

A workplace smoking ban in the Netherlands was followed by more changes in smoking and quitting than a hospitality industry ban. The hospitality industry ban only appeared to have an impact on quit attempts, and not on smoking prevalence.

Social determinants effects from the Italian risk factor surveillance system PASSI

OBJECTIVES

To offer examples on how risk factor surveillance systems can help in providing useful information on social determinants effects and health inequalities.

METHODS

The Italian risk factor surveillance system (PASSI) collects monthly information from most of the Italian Local Health Units (over 85% of the Italian population is covered) on major health-related behaviours together with information on health practices, attitudes and opinions. Multivariate analysis of associations with possible indicators of social determinants collected by the system, offers important indications on the value that the system has in providing useful information on the effects of social determinants.

RESULTS

Social determinants, although measured through very simple indicators, have major influence on health outcomes (in the example here, depression), geographical disparities in health (efficacy of smoking ban), and access to preventive services (pap test in our analysis).

CONCLUSIONS

Risk factor surveillance can offer valuable information for monitoring social determinants effects and inequalities, and, when considering data over time, for evaluating the gross impact of future interventions and policies aimed at reducing them.

Trends in principal cancer risk factors in Spain

Using data furnished by successive national health surveys, this article describes trends in the prevalence of smoking, physical inactivity, obesity, consumption of fruit and vegetables, and excessive alcohol consumption in Spain. For most of these factors, trends are shown since the end of the 1980s, and in the case of smoking, since the end of the 1970s. The findings indicate decreases in smoking--except among women aged 45-64 years--physical inactivity and high-risk alcohol consumption, and increases in consumption of fruit and vegetables, and obesity. The inclusion of these risk factors in cancer prevention strategies continues to be a matter of priority, in some cases because they display high prevalences despite their downward trend, as occurs with smoking among men and physical inactivity in the overall population, and in others because they display an upward trend, e.g. smoking among women aged 45-64 years and obesity in the overall population.

Smokefree legislation: a review of health and economic outcomes research

CONTEXT

Smokefree legislation is a powerful public health intervention. Despite progress in smokefree legislation, over half of U.S. adults remain unprotected by comprehensive smokefree legislation.

EVIDENCE ACQUISITION

This paper reviews the scientific literature on health and economic outcome studies of smokefree legislation from the past decade, 2000 to early 2010, using MEDLINE and key search terms: smoking, smoking cessation, smoking/legislation and jurisprudence, smoking cessation/legislation and jurisprudence, and health policy.

EVIDENCE SYNTHESIS

There is a wealth of research showing the health benefits to entire populations when communities implement comprehensive smokefree laws and/or regulations. These laws improve the health of hospitality workers and the general population by improving indoor air quality, reducing acute myocardial infarctions and asthma exacerbations, and improving infant and birth outcomes. Some studies report reduced smoking prevalence and cigarette consumption and improved cessation outcomes after smokefree legislation. In addition to the health benefits, economic studies confirm that smokefree laws do not adversely affect business revenues or operating costs.

CONCLUSIONS

While there is an abundance of smokefree policy outcomes research showing both the health and economic impacts of smokefree legislation, these outcomes may have more to do with implementation effectiveness than adoption, especially among subpopulations. An emerging body of literature documents not only that disparities in health protections remain among subpopulations, but that health outcomes of smokefree legislation may vary by gender, race/ethnicity, SES, and age. Further research is needed on implementation effectiveness of smokefree legislation and differential effects on subpopulations.

Smoking behaviour, involuntary smoking, attitudes towards smoke-free legislations, and tobacco control activities in the European Union

Background

The six most important cost-effective policies on tobacco control can be measured by the Tobacco Control Scale (TCS). The objective of our study was to describe the correlation between the TCS and smoking prevalence, self-reported exposure to secondhand smoke (SHS) and attitudes towards smoking restrictions in the 27 countries of the European Union (EU27).

Methods/Principal Findings

Ecologic study in the EU27. We used data from the TCS in 2007 and from the Eurobarometer on Tobacco Survey in 2008. We analysed the relations between the TCS and prevalence of smoking, self-reported exposure to SHS (home and work), and attitudes towards smoking bans by means of scatter plots and Spearman rank-correlation coefficients (r_sp). Among the EU27, smoking prevalence varied from 22.6% in Slovenia to 42.1% in Greece. Austria was the country with the lowest TCS score (35) and the UK had the highest one (93). The correlation between smoking prevalence and TCS score was negative (r_sp = −0.42, p = 0.03) and the correlation between TCS score and support to smoking bans in all workplaces was positive (r_sp = 0.47, p = 0.01 in restaurants; r_sp = 0.5, p = 0.008 in bars, pubs, and clubs; and r_sp = 0.31, p = 0.12 in other indoor workplaces). The correlation between TCS score and self-reported exposure to SHS was negative, but statistically non-significant.

Conclusions/Significance

Countries with a higher score in the TCS have higher support towards smoking bans in all workplaces (including restaurants, bars, pubs and clubs, and other indoor workplaces). TCS scores were strongly, but not statistically, associated with a lower prevalence of smokers and a lower self-reported exposure to SHS.

Biological and social predictors of smoking and perception of health

Világszerte jelentős figyelmet fordítottak a dohányzás biológiai (biológiai nem, életkor) és szociális (iskolai végzettség, foglalkoztatottság, lakóhely) jellemzőiben megmutatkozó egyenlőtlenségek vizsgálatára. Magyarországon ugyanakkor kevés elemzés történt ebben a témában. A dohányzással összefüggő morbiditási és mortalitási adatok hazai emelkedése ellenére a magyar lakosság egészségészlelése indokolatlanul optimista. Jelen tanulmányban a dohányzás biológiai és szociális prediktorjellemzőit a napi dohányzás prevalenciájával való összefüggésében, az általános egészség percepcióját pedig abban az összefüggésben vizsgáltuk, hogy a vizsgálati személyek milyennek tartották az egészségi állapotukat, és a vizsgálat időpontjában dohányoztak-e, valamint hány éves korukban kezdtek el dohányozni. A vizsgálati időszak 1990–2008 volt. A vizsgálat empirikus adatai 15, dohányzásra irányuló reprezentatív kutatás egyéni szintű adatbázisából származtak. A minta nagysága 30 352 személyt ölelt fel. GLIMMIX, GLM és logisztikus regressziós elemzést alkalmaztunk metaanalízis keretében. Az eredmények szerint a dohányzás prevalenciája a vizsgálati időszakban emelkedést mutatott. A nőknél lényegesen nagyobb volt a napi dohányzás prevalenciájának emelkedése, mint a férfiaknál. Az alacsony iskolai végzettség, a munkanélküliség és az egy lakásban élők magas száma megnövelte a napi dohányzás, a dohányzás ténye és korai kezdete pedig megnövelte a megkérdezettek saját egészségükről vallott rossz véleményének a valószínűségét. Az eredményekben megmutatkozó dohányzási tendenciák felhívják a figyelmet az eddigi hazai dohányzáspolitikák és prevenciós gyakorlat elégtelenségére, és azonnali szakmai, politikai intervenciót sürgetnek átfogó nemzeti stratégia keretében.

Legislative smoking bans for reducing secondhand smoke exposure, smoking prevalence and tobacco consumption

BACKGROUND

Smoking bans have been implemented in a variety of settings, as well as being part of policy in many jurisdictions to protect the public and employees from the harmful effects of secondhand smoke (SHS). They also offer the potential to influence social norms and smoking behaviour of those populations they affect.

OBJECTIVES

To assess the extent to which legislation-based smoking bans or restrictions reduce exposure to SHS, help people who smoke to reduce tobacco consumption or lower smoking prevalence and affect the health of those in areas which have a ban or restriction in place.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Specialised Register, MEDLINE, EMBASE, PsycINFO, CINAHL, Conference Paper Index, and reference lists and bibliographies of included studies. We also checked websites of various organisations. Date of most recent search; July 1st 2009.

SELECTION CRITERIA

We considered studies that reported legislative smoking bans and restrictions affecting populations. The minimum standard was having a ban explicitly in the study and a minimum of six months follow-up for measures of smoking behaviour. We included randomized controlled trials, quasi-experimental studies (i.e. non-randomized controlled studies), controlled before and after studies, interrupted-time series as defined by the Cochrane Effective Practice and Organization of Care Group, and uncontrolled pre- and post-ban data.

DATA COLLECTION AND ANALYSIS

Characteristics and content of the interventions, participants, outcomes and methods of the included studies were extracted by one author and checked by a second. Because of heterogeneity in the design and content of the studies, we did not attempt a meta-analysis. We evaluated the studies using qualitative narrative synthesis.

MAIN RESULTS

There were 50 studies included in this review. Thirty-one studies reported exposure to secondhand smoke (SHS) with 19 studies measuring it using biomarkers. There was consistent evidence that smoking bans reduced exposure to SHS in workplaces, restaurants, pubs and in public places. There was a greater reduction in exposure to SHS in hospitality workers compared to the general population. We failed to detect any difference in self-reported exposure to SHS in cars. There was no change in either the prevalence or duration of reported exposure to SHS in the home as a result of implementing legislative bans. Twenty-three studies reported measures of active smoking, often as a co-variable rather than an end-point in itself, with no consistent evidence of a reduction in smoking prevalence attributable to the ban. Total tobacco consumption was reduced in studies where prevalence declined. Twenty-five studies reported health indicators as an outcome. Self-reported respiratory and sensory symptoms were measured in 12 studies, with lung function measured in five of them. There was consistent evidence of a reduction in hospital admissions for cardiac events as well as an improvement in some health indicators after the ban.

AUTHORS' CONCLUSIONS

Introduction of a legislative smoking ban does lead to a reduction in exposure to passive smoking. Hospitality workers experienced a greater reduction in exposure to SHS after implementing the ban compared to the general population. There is limited evidence about the impact on active smoking but the trend is downwards. There is some evidence of an improvement in health outcomes. The strongest evidence is the reduction seen in admissions for acute coronary syndrome. There is an increase in support for and compliance with smoking bans after the legislation.

Changes in U.S. hospitalization and mortality rates following smoking bans

U.S. state and local governments have increasingly adopted restrictions on smoking in public places. This paper analyzes nationally representative databases, including the Nationwide Inpatient Sample, to compare short-term changes in mortality and hospitalization rates in smoking-restricted regions with control regions. In contrast with smaller regional studies, we find that smoking bans are not associated with statistically significant short-term declines in mortality or hospital admissions for myocardial infarction or other diseases. An analysis simulating smaller studies using subsamples reveals that large short-term increases in myocardial infarction incidence following a smoking ban are as common as the large decreases reported in the published literature.

Cardiovascular effect of bans on smoking in public places: a systematic review and meta-analysis

OBJECTIVES

A systematic review and a meta-analysis were performed to determine the association between public smoking bans and risk for hospital admission for acute myocardial infarction (AMI).

BACKGROUND

Secondhand smoke (SHS) is associated with a 30% increase in risk of AMI, which might be reduced by prohibiting smoking in work and public places.

METHODS

PubMed, EMBASE, and Google Scholar databases plus bibliographies of relevant studies and reviews were searched for peer-reviewed original articles published from January 1, 2004, through April 30, 2009, using the search terms "smoking ban" and "heart" or "myocardial infarct." Investigators supplied additional data. All published peer-reviewed original studies identified were included. Incidence rates of AMI per 100,000 person-years before and after implementation of the smoking bans and incidence rate ratios (IRRs) with 95% confidence intervals (CIs) were calculated. Random effects meta-analyses estimated the overall effect of the smoking bans. Funnel plot and meta-regression assessed heterogeneity among studies.

RESULTS

Using 11 reports from 10 study locations, AMI risk decreased by 17% overall (IRR: 0.83, 95% CI: 0.75 to 0.92), with the greatest effect among younger individuals and nonsmokers. The IRR incrementally decreased 26% for each year of observation after ban implementation.

CONCLUSIONS

Smoking bans in public places and workplaces are significantly associated with a reduction in AMI incidence, particularly if enforced over several years.

A smoking ban in public places increases the efficacy of bupropion and counseling on cessation outcomes at 1 year

INTRODUCTION

Legal restrictions have contributed to the decline in smoking prevalence in several European countries. We investigated the impact of the Italian 2005 indoor smoking ban on the efficacy of counseling alone or in combination with bupropion for smoking cessation.

METHODS

Before and after the introduction of the ban (2001-2006), 550 smokers were enrolled in the smoking cessation program in Rome and were asked to choose between a 6-week group counseling therapy (GCT) given alone or in combination with 7 weeks of daily bupropion. Follow-up was completed 12, 26, and 52 weeks after the quit day. Due to the observational nature of the study, we used propensity scores to match 138 and 290 subjects (pre-/postban) in the bupropion- and GCT-only groups, respectively.

RESULTS

Covariate balance in the two matched samples was adequate for all variables except "coffee consumption" in the GCT-only group. The regression adjusted odds ratios indicated that the introduction of the ban resulted in 52% reduced odds of continued smoking at 12 months among the GCT + bupropion group and 41% reduced odds in the GCT-only group. We observed that the ban was associated with both increased 12-month abstinence rates and motivation to quit. In a mediation analysis, we determined that the total effect of the smoking ban on the abstinence rate was reduced after controlling for motivation, which confirmed that motivation was a partial mediator.

DISCUSSION

The introduction of an indoor smoking ban improved the efficacy of smoking cessation treatments by possibly providing a setting that increased the level of motivation to stop smoking.

Impact of the Spanish smoking law in smoker hospitality workers

INTRODUCTION

A smoke-free law went into effect in Spain on 1 January 2006, affecting all enclosed workplaces except hospitality venues, where only partial bans were implemented. The objective was to evaluate the impact of the law among hospitality workers who smoke.

METHODS

The study design is a before-and-after evaluation. We formed a cohort at baseline, during the 3 months before the law went into effect, with 431 hospitality workers (222 smokers). From them, 288 were successfully followed-up 12 months after the ban (118 were smokers at baseline). We analyzed the quit rate, the reduction in the number of cigarettes smoked per day, changes in the Fagerström Test for Nicotine Dependence (FTND) scores, and changes in salivary cotinine concentrations in smokers from baseline to 1 year after the ban.

RESULTS

Among 118 smokers, six (5.1%) quit smoking. Among the 112 remaining smokers, the mean number of cigarettes smoked decreased by 8.9% after the ban (from 17.9 to 16.3 cigarettes/day, p < .01). The proportion of workers with a high nicotine dependence (FTND score >6) was reduced by half after the ban (19.5% vs. 9.7%, p = .03). Salivary cotinine decreased by 4.4% after the ban (geometric mean 104.3 vs. 99.7 ng/ml, p = .02). No meaningful differences were found in quit rates and the FTND scores according to type of regulation.

DISCUSSION

The Spanish smoking law has had beneficial effects (reduction in number of cigarettes smoked, cotinine levels, and FTND score) among hospitality workers who smoke.